Surgery Services: Introduction

Surgical procedures must be performed in a podiatrist's office, in a hospital, or in a freestanding ambulatory surgical center. (A) Provider Eligibility. The MassHealth agency pays a podiatrist for surgery only if the podiatrist is scrubbed and present in the operating room during the major portion of the operation. (B) Nonpayable Services. The MassHealth agency does not pay for (1) any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment; (2) reconstructive surgery, unless the MassHealth agency determines, pursuant to a request for prior authorization, the service is medically necessary to correct, repair, or ameliorate the physical effects of disease or physical defect, or traumatic injury; (3) services billed under codes listed in Subchapter 6 of the Podiatrist Manual as not payable; (4) services otherwise identified in MassHealth regulations at 130 CMR 424.000 or 450.000: Administrative and Billing Regulations as not payable; and (5) services billed with otherwise-covered service codes when such codes are used to bill for nonpayable services as described in 130 CMR 424.405. (C) Definitions. The following terms have the meanings given for purposes of 130 CMR 424.413 and 424.414, unless otherwise indicated. (1) Complications Following Surgery – all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room. (2) Evaluation and Management (E/M) Services – visits and consultations furnished by physicians in various settings and of various complexities as defined in the Evaluation and Management section of the American Medical Association’s Current Procedural Terminology (CPT) code book. (3) Intraoperative Services – intraoperative services that are normally a usual and necessary part of a surgical procedure. (4) Major Surgery – a surgery for which the Centers for Medicare & Medicaid Services (CMS) determines that the preoperative period is one day and the postoperative period is 90 days. (5) Minor Surgery – a surgery for which CMS determines the preoperative period is zero days and the postoperative period is zero or 10 days. (6) Postoperative Period – (a) The postoperative period for major surgery is 90 days. (b) The postoperative period for minor surgery and endoscopies is zero or 10 days. (7) Postoperative Visits – follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. (8) Postsurgical Pain Management – postsurgical pain management by the surgeon, including supplies. (9) Preoperative Period – (a) The preoperative period for major surgery is one day. (b) The preoperative period for minor surgery is zero days. (10) Preoperative Visits – preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.